Narcotic and Controlled Substances Management Policy Update 2012
Narcotic and Controlled Substances • The LHSC Narcotic and controlled Substances Management Policy has been revised following recommendations from the ISMP report and Accreditation in the fall of 2011 • The primary goals of the Narcotic and Controlled Substances Management Policy are: • To provide a clear process for the management of these medications • To ensure consistent and safe practices while dispensing, administering, storing and disposing of narcotics and controlled substances.
Narcotic and Controlled Substances Key Highlights • Patient’s own narcotics and controlled substances section added • LHSC discourages the use of patient’s own narcotics whenever possible • This section outlines the process for safely managing narcotics and/or controlled substances that are brought into hospital by a patient • Management of wastage • Clearly defines how to manage wastages in all areas • Addition of how to render/dispose of small and large amounts of narcotics in a safe manner
Narcotic and Controlled Substances Key Highlights • Area Leadership responsibility • Detailed roles and responsibility including periodic audits and reviews to ensure proper management of narcotics and controlled substances in their area. • Increased focus on AEMS reporting • Highlights the importance of completing an AEMS report and the identification of appropriate situations to complete the report • Roles and responsibilities of different health care team members in AEMS reporting.
Narcotic and Controlled Substances Key Highlights • Shift count process • Clearly outlines the process for shift count, who must complete the count, when a new disposition record is required, and steps to follow if there is a discrepancy with the count • Documentation of narcotics and controlled substances • A more thorough and safe approach to documentation has been outlined. Meant to address ongoing challenges in areas of legibility, thoroughness and timely completion of this document.
Narcotic and Controlled Substances Reminders • Document clearly and legibly on both the MAR and the narcotic disposition record. • Narcotic cupboard keys are still to be counted with each shift change count and documented as per unit practice For any questions or concerns contact: • Unit leadership • Pharmacy/unit pharmacist • Nursing professional practice
Narcotic and Controlled Substances Questions? • Contacts • Nursing Professional Practice OR • Pharmacy